University Records
Program Withdrawal/Leave of Absence Cancellation
Select One
Personal Information
Student Acknowledgement
Return the completed form to University Records via your LLU email address to,
fax it to (909) 558-0340, or bring it to the office at 11139 Anderson Street, Loma Linda, CA 92354
I hereby request to rescind/cancel my previoiusly submitted leave of absence/program withdrawal
request. I understand and agree to the following:
1. I intend to remain in academic attendance through the end of the current enrollment period
2. If I decide that I do indeed wish to withdraw during this enrollment period after submitting this
cancellation request the official withdrawal date will be reverted back to the first date I told the
University of my intent to withdraw or began the LOA/PW process, unless my school is able to
document a later date of attendance at an academically related activity
Student Name
Student Information
LLU School
Student Signature:
Student ID#
By checking this box and signing below I understand and agree to the above statement
Academic Dean/Program Director Signature: